Paediatrica Indonesiana
VOLUME 55 November ‡
PELOD score, serum procalcitonin,
and lactate levels in pediatric sepsis
Jufitriani Ismy1, Munar Lubis1, Erna Mutiara2, Gema Nazri Yani1, Yunnie Trisnawati1
Abstract
Background Sepsis remains a major cause of morbidity and
mortality among critically ill children in the pediatric intensive
care unit (PICU). Procalcitonin and lactate have been used as
biomarkers of sepsis, as they have been correlated with disease
severity, organ failure and death. The Pediatric Logistic Organ
Dysfunction (PELOD) score is a tool to assess the severity of
organ dysfunction in critically ill children.
Objective To investigate the correlation between PELOD score
and procalcitonin and lactate levels in pediatric sepsis.
Methods A cross-sectional study was conducted in children
with sepsis who were admitted to the PICU from April to July
2012. Sepsis was defined as systemic inflammatory response
syndrome (SIRS), as a result of suspected or proven infection.
Proven infection was defined as positive culture findings (blood,
NUMBER 6
Original Article
S
epsis remains a major cause of morbidity and
mortality among critically ill children in the
PICU.1,2 Physicians should be able to carefully
monitor patient response to therapy, including
the progression to septic shock, organ failure, or death.
In addition to their use in sepsis diagnosis, biomarkers
have been used to complement clinical assessments
and provide information for diagnostic, monitoring
and therapeutic decision-making at various levels
of sepsis.3,4 Biomarkers are useful to monitor disease
course as testing is generally noninvasive and yields
quick results.5
Procalcitonin and lactate are biomarkers of
XULQH RU RWKHU VSHFLPHQV DQGRU VHUXP SURFDOFLWRQLQ • QJ sepsis, where increased serial levels have been
mL. Spearman’s test was used to assess for correlations between
PELOD scores and procalcitonin as well as lactate levels.
suggested to be good prognostic markers.5,6 Several
Results Thirty-two patients were analyzed, consisting of 18 males studies have shown the correlation between
and 14 females with an age range of 1-432 months (median 21 procalcitonin and severity of disease and organ
months). There was no statistically significant correlation between failure.6-8 The PELOD score is used to assess organ
procalcitonin level and PELOD score (r=- 0.186, 95%CI -0.502
to 0.174, P=0.308) nor between lactate level(r=-0.069, 95%CI
-0.408 to 0.287, P=0.709) and PELOD score.
Conclusion Serum procalcitonin and lactate levels are not
correlated with PELOD scores in children with sepsis. This study was presented at the Pertemuan Ilmiah Ilmu Kesehatan Anak V/
PIT IKA V (The 5th Child Health Scientific Meeting), Bandung, Indonesia,
[Paediatr Indones. 2015;55:293-6].
October 15-17, 2012.

Keywords: sepsis, procalcitonin, lactate, PELOD From the Department of Child Health, University of Sumatera Utara
score Medical School1 and School of Public Health2, Univeristy of Sumatera
Utara Medical School/H. Adam Malik General Hospital, Medan,
Indonesia.

Reprint requests to: dr. Jufitriani Ismy, Department of Child Health,

University of Sumatera Utara Medical School/H. Adam Malik Hospital,
Jl. Bunga Lau No.17, Medan, Indonesia 20136. Tel. +6261 8361721 –
+6261 8365663; Fax. +6261 8361721; E-mail: fitriismy@yahoo.com.

3DHGLDWU,QGRQHV9RO1R1RYHPEHU‡293
 Jufitriani Ismy et al: PELOD score, serum procalcitonin, and lactate levels in pediatric sepsis

dysfunction in multiple organ systems.9 The PELOD Results

scores increase along with the cumulative effect of
organ dysfunction and severity of sepsis.10 There Thirty-two septic patients were admitted to the PICU.
have been few studies on whether these biomarkers Table 1 shows the demographic characteristics of
and PELOD score are strongly correlated; also results subjects. The majority of subjects (13/32) were 1
so far have been conflicting.11,12 The aim of our to 12 months of age. The most common primary
study was to assess the correlations between PELOD source of the sepsis was respiratory (10/32). Table 2
scores and lactate as well as procalcitonin levels in shows the median serum procalcitonin and lactate
children with sepsis. levels, as well as PELOD scores. Table 3 shows there
was no significant correlation between procalcitonin
level and PELOD score (r= - 0.186, P=0.308), nor
Methods between lactate level and PELOD score (r= -0.069,
P=0.709).
This cross-sectional study was conducted in the
PICU at Haji Adam Malik Hospital, Medan, North
Sumatera, and included all septic patients. The
study was conducted in April-July 2012. Subjects Table 1. Demographic data of subjects
were septic children aged 1 to 432 months, with a Characteristics (N=32)
PICU length of stay >24 hours, and whose parents Age, n
provided informed consent. Patients with septic 1-12 mo 13
13-60 mo 10
shock were excluded. Sepsis was defined as SIRS in 61-144 mo 6
the presence or as a result of suspected or proven 145-180 mo 2
infection. Proven infection was defined as positive 18-432 mo 1
Gender, n
culture findings (blood, urine or other specimens) Male 18
DQGRUSURFDOFLWRQLQ•QJP/ Female 14
All patients underwent complete blood Nutritional status, n
Well-nourished 19
count examinations, liver and renal function tests,
Moderately undernourished 7
hemorrhagic screening tests, and blood gas analyses. Severely undernourished 5
Serum procalcitonin and lactate levels were also mea- Overweight 1
sured in all septic patients and PELOD scores were Blood culture result, n
Positive 15
calculated after the diagnosis of sepsis was confirmed. Negative 17
Examinations were done within the first of 24 hours. Primary disease, n
For the PELOD score, six organ systems (neurologic, Respiratory 10
Cardiovascular 1
cardiovascular, renal, respiratory, hematologic, and Gastroenterological 1
hepatic) were evaluated, each with up to 3 variables Neurological 4
(total of 12 variables). Each variable was assigned 0, Post -neurosurgerical 8
Post-gastrosurgical 7
1, 10, or 20 points based on the level of severity. Each Post-thoracosurgical 1
variable was scored and summed for the total PELOD
score. Study approval was obtained from the Research
Ethics Committee of the North Sumatera University
Medical School. Table 2. Median procalcitonin and lactate levels and PELOD
Spearman’s test was used to assess for cor- scores
relations between either procalcitonin or lactate Variables Median (range)
level and PELOD score and findings was presented as (N=32)
correlation coefficient with corresponding confidence Procalcitonin, ng/mL 10.5 (0.13-100)
Lactate, mmol/L 2.15 (0.3-6.8)
interval. A P value of <0.05 was considered as statis- PELOD score 16 (0-40)
tically significant. We analyzed data by SPSS version
15.0 software.

294‡3DHGLDWU,QGRQHV9RO1R1RYHPEHU
 Jufitriani Ismy et al: PELOD score, serum procalcitonin, and lactate levels in pediatric sepsis

Table 3. Correlations between PELOD score and procalcitonin and lactate levels
PELOD score R 95% CI P value
Ů
Procalcitonin, n
0.10-0.25 ng/mL 0 0 2 -0.186 -0.502 to 0.174 0.308*
1.01-5.00 ng/mL 3 1 5
5.01-100 ng/mL 7 5 9
Lactate, n
<2 mmol/L 4 1 7 -0.069 -0.408 to 0.287 0.709*
ŮOOQN. 6 5 9
* Spearman’s correlation test

with bacterial sepsis who had persistent multiple organ

Discussion
Our study showed that neither procalcitonin nor
lactate level had strong correlation with PELOD
score. Of our 32 PICU patients, 47% of the children
had positive blood cultures. The initial conditions that
led to sepsis were respiratory disease (10 subjects),
post-neurosurgery (8 subjects), post-gastrosurgery (7
subjects), and neurologic disease (4 subjects). Similarly,
an Indian study found that the most common primary
source of sepsis was respiratory disease (pneumonia) in
73.3% of patients, but only 3 (10%) of their patients
had positive cultures.12A Japanese study found a blood
culture sensitivity of 42.6% in 47 sepsis patients.13
failure.17 Furthermore, a Canadian study showed that
PELOD assessment scores for a specific set of 7 days
(day 1, 2, 5, 8, 12, 16, and 18) can provide optimal
information about evolving organ failure during treat-
ment in the PICU.15
A Bandung study showed a significant association
between plasma lactate level and the degree of organ
dysfunction based on PELOD scores in 45 subjects with
an average age of 48.7 months. Subjects were grouped
DFFRUGLQJWRODFWDWHOHYHOVPPRO/RU•PPRO/
Most of their subjects experienced cardiovascular
events, had mean lactate levels of 3.45 mmol/L, and
the average had dysfunction in 3 organs.18 In our study,
the median lactate level was 2.15 mmol/L. We grouped
The median PELOD score in our subjects was
16 on day one. A German study found the median
PELOD score to be 10 in 965 (54%) children.10 Also,
a study in Manado reported a median PELOD score of
8 in 26 (70.2%) children with sepsis.14 Furthermore,a
study in Canada, Germany, and Switzerland found
VXEMHFWVDFFRUGLQJWRODFWDWHOHYHORU•PPRO/
but found no association between plasma lactate level
and the degree of organ dysfunction based on PELOD
scores. A study in Australia showed that lactate levels
were the earliest predictor for assessing outcomes in
31 children with sepsis. Lactate level assessments were
WKDWDKLJK3(/2'VFRUH•SRLQWVRQGD\RQH
was associated with death, and mortality rate was
50% when a high score on day one increased on day
two.15
Five subjects had procalcitonin levels of 100 ng/
ml. Their PELOD scores were 1 in one child, 12 in two
children, and 22 in two children. In our study, there
was no correlation between procalcitonin level and
PELOD score. A London study in 75 children with
septic shock determined that children with higher
admission procalcitonin levels ultimately had worse
organ failure and lower survival.16 In addition, an
American study found that procalcitonin concentra-
tion was increased among children with sepsis on day
1 (2.4 ng/mL), but not on day 3 (0.8 ng/mL), and pro-
calcitonin was continuously increased among patients
made at 12 hours, 24 hours and 48 hours after PICU
admission.19 Lactate levels in our study were examined
when patients were admitted to the PICU but after
the diagnosis of sepsis was confirmed. No further serial
lactate levels were investigated. The PELOD scores
were assessed at PICU admission, after the diagnosis
of sepsis was confirmed, but were not reassessed on
following days.
This study had several limitations: a relatively
small sample size (32 patients) and subjects were not
grouped by source of sepsis. The small sample size
may be associated by the fact that we did not find
any statistically significant correlation between either
lactate or procalcitonin levels and PELOD score and
thus further research with larger sample size is required
to confirm the findings.
3DHGLDWU,QGRQHV9RO1R1RYHPEHU‡295
 Jufitriani Ismy et al: PELOD score, serum procalcitonin, and lactate levels in pediatric sepsis
In conclusion, PELOD score appears not
correlated with either procalcitonin or lactate levels
in children with sepsis.
Conflict of Interest
None declared.
References
1. Wynn J, Cornell TT, Wong HR, Shanley TP, Wheeler DS. The
host response to sepsis and developmental impact. Pediatrics.
2010;125:1031-41.
2. Proulx F, Fayon M, Farrell CA, Lacroix J, Gauthier M.
Epidemiology of sepsis and multiple organ dysfunction
syndrome in children. Chest. 1996;109:1033-7.
3. Standage SW, Wong HR. Biomarkers for pediatric sepsis and
septic shock. Expert Rev Anti Infect Ther. 2011;9:71-9.
4. Kaplan JM, Wong HR. Biomarker discovery and development
in pediatric critical care medicine. Pediatr Crit Care Med.
2011;12:165-73.
5. Ventetuolo CE, Levy MM. Biomarkers: diagnosis and risk
assessment in sepsis. Clin Chest Med. 2008;29:591-603.
6. Rey C, Los Arcos M, Concha A. Procalcitonin as diagnostic
and prognostic marker in critically ill children. Eur Pediatr.
2010;4:62-5.
7. Pierrakos C, Vincent JL. Sepsis biomarkers: a review. Crit
Care. 2010;14:1-18.
8. Castelli GP, Pognani C, Meisner M, Stuani A, Bellomi
D, Sgarbi L. Procalcitonin and C-reactive protein during
systemic inflammatory response syndrome, sepsis and organ
dysfunction. Crit Care. 2004;8:234-42.
9. Leteurtre S, Martinot A, Duhamel A, Gauvin F, Grandbastien
B, Nam TV, et al. Development of a pediatric multiple organ
dysfunction score: use of two strategies. Med Decis Making.
1999;19:399-410.
296‡3DHGLDWU,QGRQHV9RO1R1RYHPEHU
10. Leclerc F, Leteurtre S, Duhamel A, Grandbastien B, Proulx F,
Martinot A, et al. Cumulative influence of organ dysfunctions
and septic state on mortality of critically ill children. Am J
Respir Crit Care Med. 2005;171:348-53.
11. Jensen JU, Heslet L, Jensen TH, Espersen K, Steffensen P,
Tvede M. Procalcitonin increase in early identification of
critically ill patients at high risk of mortality. Crit Care Med.
2006;34:2596-602.
12. Jat KR, Jhamb U, Gupta VK. Serum lactate levels as the
predictor of outcome in pediatric septic shock. Indian J Crit
Care Med. 2011;15:102-7.
13. Aikawa N, Fujishima S, Endo S, Sekine I, Kogawa
K, Yamamoto Y. Multicenter prospective study of
procalcitonin as an indicator of sepsis. J Infect Chemother.
2005;11:152-9.
14. Hendra, Runtunuwu AL, Manoppo JIC. Pediatric logistic
organ dysfunction (PELOD) score as prognosis of multiple
organ failure in sepsis. Paediatr Indones. 2010;50:226-
32.
15. Leteurtre S, Duhamel A, Grandbastien B, Proulx F, Cotting J,
Gottesman R, et al. Daily estimation of the severity of multiple
organ dysfunction syndrome in critically ill children. CMAJ.
2010;182:1181-7.
16. Hatherill M, Tibby SM, Turner C, Ratnavel N, Murdoch
IA. Procalcitonin and cytokine levels: relationship to organ
failure and mortality in pediatric septic shock. Crit Care Med.
2000;28:2591-4.
17. Han YY, Doughty LA, Kofos D, Sasser H, Carcillo JA.
Procalcitonin is persistently increased among children with
poor outcome from bacterial sepsis. Pediatr Crit Care Med.
2003;4:21-5.
18. Budi AD, Rosalina R, Sekarwana N. Hubungan kadar
laktat plasma dengan derajat disfungsi organ berdasarkan
skor PELOD pada anak sakit kritis. Sari Pediatri. 2008;
10:280-4.
19. Duke TD, Butt W, South M. Predictors of mortality and
multiple organ failure in children with sepsis. Intensive Care
Med. 1997;23:684-92.